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  5. Cognitive Test
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Hello:
You are invited to participate in our test survey for cognitivetest.com. In this survey, approximately 10 people will be asked to complete a survey that asks questions about information we might like to collect. It will take approximately 2 minutes to complete the questionnaire.

Your participation in this study is completely voluntary. There are no foreseeable risks associated with this project. However, if you feel uncomfortable answering any questions, you can withdraw from the survey at any point. It is very important for us to learn your opinions.

Your survey responses will be strictly confidential and data from this research will be reported only in the aggregate. Your information will be coded and will remain confidential. If you have questions at any time about the survey or the procedures, you may contact [Name of Survey Researcher] at [Phone Number] or by email at the email address specified below.

Thank you very much for your time and support. Please start with the survey now by clicking on the Continue button below.

 
 
 
 
Have you heard of the term "cognitive test"?
 
Yes
 
No
 
 
 
Have you heard of the term "brain health"?
 
Yes
 
No
 
 
 
Do you know your total cholesterol?
 
Yes
 
No
 
 
 
Do you know your average blood pressure?
 
Yes
 
No
 
 
 
How often do you visit your family physician?
 
As needed
 
Monthly
 
Quarterly
 
Annually
 
 
 
Do you have traditional Medicare?
 
Yes
 
No
 
 
 
Do you participate with a Medicare Advantage health plan (managed Medicare) like Humana or United Healthcare?
 
Yes
 
No
 
 
 
If you participate in traditional Medicare, do you carry a supplement?
 
Yes
 
No
 
N/A
 
 
 
Have you every had anyone comment about your memory?
 
Yes
 
No
 
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